The choice by staff at Cork University Hospital to send the organs of 18 deceased babies for incineration with clinical hospital waste was “a misguided decision and a deviation from local policy and national standards,” an expert review into the incident has found.
The “systems analysis review” into the sending of the baby organs to Denmark for incineration in March and April 2020 found that it was “an isolated incident due to severe pressure on the Post-Mortem Room Team in unprecedented circumstances in preparation for the Covid 19 pandemic”.
According to the review team, which was headed up by consultant histopathologist, Dr Sean O’Briain of Blackrock Clinic and formerly St James’s Hospital, the post-mortem room team have stated that they “very much regret” the actions that they took.
Dr O’Briain’s team also acknowledged in their 124-page report, which was delivered to the 18 affected families on Friday morning, “the distress experienced by the parents as a result of what has occurred and a consequence of the delay in completing this report”, which was first promised in November 2021.
Newly appointed CEO of Cork University Hospital David Donegan also apologised in a letter to the families in which he acknowledged both the upset that the incident caused and the distress that the delay has caused.
“I acknowledge that we let you down in respect to the disrespectful disposal of your baby’s post-mortem organs. This was one of the most difficult times in your lives and we are incredibly sorry for that,” said Mr Donegan.
“I appreciate that those words may bring little comfort to you, and that the best I am likely to be able to offer is furnishing you with the final review, which explains what happened, why it happened and what we have and will do to address the Review Team’s findings.”
The report said that both the Review Team and CUH were very cognisant of the length of time it has taken to complete the review and in this regard, analysis will be undertaken of the methodology with a view to establishing what type of review could and or potentially should have been used.
“Also going forward, it is essential that a review of a patient safety incident is completed in a timely manner so that patients, families and staff are not waiting an extraordinary length of tie for the review to complete. This leads to lost opportunities for learning,” it stated.
A mother whose deceased baby’s organs were sent for incineration without her knowledge or consent criticised the report, saying it doesn’t provide her with the answers she needs to help her grieve for her baby and achieve closure.
Katie Quilligan from Carrignavar, whose two-day old baby James passed away at Cork University Maternity Hospital (CUMH) on January 19th 2020, said that while she had yet to study the 124 page report in detail, she didn’t believe on first reading that it answered any of the questions she has.
“When I read the accompanying letter from David Donegan of Cork University Hospital that they sent with the report, that they regretted ‘letting me down’, I thought they haven’t let us down, they have broken us because there isn’t even a proper apology to us for what they did to us all.”
“They surely don’t think we are going to accept ‘we let you down’ as an apology – they are saying they are sorry but meet us and tell us that face to face – we’re allowed meet the review team but are we allowed to meet the people who did it and sent our babies’ organs for incineration?”
Ms Quilligan said she found some of the detail of the report, including the fact her baby’s brain was put in a container with the organs from other deceased infants from CUMH along with body parts from patients at CUH deeply upsetting.
“What they are saying in the report is that each baby’s organ had its own box and then for them to throw all the organs into one box including body parts of people from Cork University Hospital, that’s actually after making me more upset, when I read that,” she said.
“Knowing that my baby’s little brain went from being in its own little box to being put into a box with the brains of six other little babies and body parts from other patients at Cork University Hospital and then shipped off for incineration abroad, that has really upset me.
“I wanted the names of the people who did this, I wanted to know step by step how it happened whereas they’re just telling us ‘It was put into a box and sent off for incineration’. I don’t know what to believe any more and I don’t think this is going to give me the closure that I want.”
“I want the people who physically did this and the people who signed off on this, to look us straight in the face and apologise and I want the Minister for Health to meet us rather than apologising on the telly or in the Dáil. Why are they so afraid to meet us face to face and look us in the eye?”